18 gauge insertion

steelcityrn, RN · Apr 5, 2008

I was just going to add my 2 cents . I have to also add the importance of taking your time. I hold the arm with my left hand well to control the position of the incertion site. Drop the needle down as soon as you see a flash, or once you have 1/4 of the catheter in. Apply pressure above the site, then release the tournquet. Then apply one piece tape to secure for now.I always have my line flushed and ready to apply. Then secure the site well and dress. I always start on the hands(non dominent side first), then work up. I agree with the need to keep your confidence up. The only difference with 18's for me is once I pick my site, I incert slightly lower to allow for the extra length.

back2bRN · Apr 5, 2008

Where I work our 18 and 20's are the same length. So you get used to dealing with the extra length. What I find to be most helpful is preparing the pt. By that I mean I typically wrap their arms in warm blankets before I prepare the IV tubing. I also use an 18 as a general rule. If the pt has fragile veins, I ascribe to the "any hole" theory. I can always start another line once condition has changed. I also find that I take my time, be methodical and follow my instincts. But there will always be the young healthy male athlete that you have to take two goes at!! Also where I work I am it, I have to get them, there is usually only 1 other RN on, away from the ED. No IV team.

ozinurse · Apr 5, 2008

I woul have to agree with some of the other posters that attitude and confidence often contributes to about 90% of success rate. Another big cause of failure that I have noted, is clinicians not being in a comfortable and inline position.

Generally the technique of sticking in an 18 is much the same for the smaller guages except that the receiving vessel also has to be adequate to accomodate the size. One thing to keep in mind though is the length of the bezel is consideably longer in the 18 compared to the smaller, which means that you need to be careful as your needle can pass through the vessel, especially if you are on too sharp (no pun intended) an angle.

This is the reason that technique changes slighlty when you reach size 16. The tip of the bezel can be most of the way through the vesel, before the 'flashback' is capable of traveling up the bore of the needle. You generally have to use a shallower angle, and the signalling flashback is generally only a small spurt, rather than a flow into the flashback chamber (unless you are in something huge). By the time there is a good flow the tip of the needle is peircing the far wall of the vessel.

The distance from the end of the cannula relative to the end of the needle is also imprtant to keep in mind, as if the needle has not been inserted far enough before advancing the cannula, the vessel may be pushed off the end. These are often those ones when you were sure you were in and you blow it when you advance.

Getting the technique right on 'the sure thing' helps with confidence. Just don't limit yourself to the anterior cubital fossa, as it will drive everyone nuts.

Local anaesthetic (0.1-0.2mL 1% lignocaine for injection) goes a long way as well. There are some articles out there, suggesting that it decreases the pain by half and doesn't impede success rate. It will make the patient more comfortable and relaxed, and take the stress out of the pain you inflict if you miss or 'have to dig' a bit (hopefully not too much).

ozinurse · Apr 5, 2008

If you are apprehensive when before you start, you will probably miss.

Start on the sure things, then progress to the more difficult as your confidence builds.

Get some one you can take criticism from an is good at cannulating to watch you.

If you miss, critique yourself. If you can identify the problem, don't do it again.

Some simple points to success.

- technique should be fluent/fluid

- be confident

- be comfortable

- Don't rush it.

- picture the vessel in your head and the cannula in relation to it.

BornHealer · Apr 7, 2008

Oh -- reading your post brought me back many moons ago, when I started ER nursing. I agree 100% with "greenjanell". You're psyching yourself out. I started ER right out of school ---Green as a Granny Smith Apple. The ER was a Level I Trauma Center - So anything less than an 18G wasn't even considered an IV access and many times the trauma surgerns wanted 14G and 16G. (for valid reasons - but I was new -- to everything!!) What I started realizing is that when no one else was around -- My skills improved dramatically. It wasn't that I couldn't do it. I lacked confidence. Every mistake made in front of a co-worker was amplified 100 times worse in my mind. Skills take a long time to perfect and ER's are fast paced -- many times you're working under great stress. Starting IV's takes practice. My advice is keep working with the 18G and don't automatically go for the 20G because you feel more comfortable. You will eventually be comfortable with the 18G and when the situation presents itself, when only a large bore access is appropriate -- you'll be able to get it in --just like a pro. Take care, Murse 7. Remember, we nurses are sometimes our own worse enemy. G00d Luck. :nurse:

SuperStockRN · Apr 8, 2008

I think it is great that everyone has their own technique - DO WHAT WORKS FOR YOU!!!

However, if you ARE having problems, my 2 cents would be to make sure you are "palpating" the vein and not relying on sticking what you can see. I have seen this with a lot of new nurses, and I was guilty of doing the same thing.

I was lucky enough to be taught to:

- palpate the vein, evaluating its location and length and size.

- palpate an approximate insertion site (if direct insertion).

-palpate around your approx. site to evaluate if it is straight, curving, diagonal, etc. This will facilitate threading it in once you get the flash. It will also tell you if its particularly "rolly".

-if it is curvy, etc consider an indirect approach to eventually land/thread the end of the catheter into the most straight portion.

-Do not poke what you are not confident you can atleast "hit". This doesn't mean to not try if you don't see anything. Perhaps ask another staff to help you find it before conceeding to asking them to completely do it for you.

-Like others have said, GET EXPOSURE. The more the better. Sample everyones styles and develop your own.

AS FAR AS 18GA.:

I agree that short of a resucitation or a trauma, the time you would waste not getting the 18ga, you could have been infusing with a 20ga just fine. 18 ga. are more rigid and are more prone to fail threading, so I stick to the methods above to know what direction I am trying to thread.

CONFIDENCE AND PRACTICE. You can do it! ! ! ! !

Seemoni · Apr 10, 2008

Wow, I wouldn't say that attempting an 18g is a waste of time at all. I have been in the ER for almost 6 months now and 18's are my mainstay. They're pretty much all I start. I feel a bit defeated if all I can get is a 20g. I know that for most part a 20g is perfectly fine for things short of fluid resuscitation. However, being able to stick an 18g in just about anyone is really helpful, cause usually when you actually need one the pressure is on and it becomes that much more difficult. If it's a habit, there's no big deal about it. Just keep practicing with it and use the larger one if you can. After a few weeks of 18's only you'll have no problem at all, then try 16's when you can because those actually do feel pretty different, you have to get a certain "popping" sensation with them and advance with the needle a lot further cause the bevel is so large you can start advancing into the vein wall if you're not careful. Actually make sure you're doing that with your 18s. After you get a flash, don't thread immediately. Your bevel tip may be beneath the vessel wall but the entire needle may not have gone into it and you don't want to advance without being all the way in or you're just tearing/blowing the vein then. Get the flash, slowly advance a bit more, than thread. Voila.

ozinurse · Apr 10, 2008

I would imagine the use of 18g cannula on everyone is a generalisation.

I think the size of the cannula inserted needs some discression. It is not necessary to insert large bore cannulas in stable patients only requiring maintence fluids or intermittent antibiotics.

However, I am in agreement that caution should be made, and insertion of a larger cannula when the patient is or potentially unstable, and/or requiring fast fluids or blood administration. The nature of emergency department, is that patient diagnosis is often unclear and an 18g cannula in these patients is appropriate.

It is admittedly a lot more annoying to see inappropriately small cannulas insert into sick people. I have heard the excuse, that it is all they could get in. Maybe they should have gotten someone who was capable of stick the correct size in to do the job. :twocents:

ZippyGBR, BSN, RN · Apr 10, 2008

I would imagine the use of 18g cannula on everyone is a generalisation.
I think the size of the cannula inserted needs some discression. It is not necessary to insert large bore cannulas in stable patients only requiring maintence fluids or intermittent antibiotics.
However, I am in agreement that caution should be made, and insertion of a larger cannula when the patient is or potentially unstable, and/or requiring fast fluids or blood administration. The nature of emergency department, is that patient diagnosis is often unclear and an 18g cannula in these patients is appropriate.
It is admittedly a lot more annoying to see inappropriately small cannulas insert into sick people. I have heard the excuse, that it is all they could get in. Maybe they should have gotten someone who was capable of stick the correct size in to do the job.

if you are going in an ACF because you can't get a hand or forearm vein then bigger is better if this might end up being the 'lifeline'

too many people won't use forearm veins - these are often the best option unless the patient has 'big' hands -as a cannula i nthe dorsum of the patient's hand will irritate and run the risk of getting knocked out a lot easier

LilgirlRN, ADN, RN · Apr 10, 2008

When I worked nights I would get called allover the hospital to gain IV access for a patient. To me, 18's aren't always the answer, put in what you can get in until you pump them up with some fluids. I've put 18's in thumbs, in shoulders, AC's but when putting in something that big I numb the patient first. Some people say that the bleb from the lidocaine obstructs their view of the vein, to me it's psychological. If I know I'm not hurting the patient I feel better about wiggling the needle around.

ozinurse · Apr 11, 2008

I am a huge fan of local anaesthetic.

There are several articles that suggest the use of lignocaine decreases the pain of cannulation (and abg's (Lightowler and Elliot (1997 and Giner et al 1996)) by half. (Robinson et al 2007, Murphy and Carley 2000 and Harris 2001) and also if used correctly, that it doesn't effect the success rate (Murphy and Carley 2000).

I use it when inserting 20-16g cannula, and have had an excellent patient response. Despite working in a 'best practice' driven environment it is still difficult to get people to use local. The (false) perception that it makes it more difficult is one of the reasons it isn't taken on.

As an advocate for the patients well being, simple measures to ensure that the patients hospital managament is as un-unpleasant as possibleis (I believe) it is important. Just because they have come to the emergency department, doesn't mean that we have a right to inflict unnecassary pain on them. We often think that they should just grit there teeth, or show some gumption, but from my experience, cannulas hurt.

The same principles would also pertain to other pain inducing procedures, such as NG insertion. Female catheterisation (Chung et al 2007). If your department doesn't already have analgesia incorporated into these procedures, it is worthwhile at least having standing orders so that you have the option.

Chung C, Chu M, Paoloni R, O'Brien M and Demel T 2007, Comparison of lignocaine and water-based lubricating gells for female urethral catheterisation: a randomised controlled trial, Emergency Management Australasia, 19, pp. 315-319.

Giner J, Casan P, Belda J, Gonzales M, Miralda R and Sanchis J 1996, Pain during arterial puncture, The American College of Chest Physicians, vol. 110, no. 6.

Harris T, Cameron P and Ugoni A 2001, The use of pre-cannulation local anaesthetic and factors effecting pain perception in the emergency department setting, Emergency Medicine Journal, 18, pp. 175-177.

Murphy R and Carley M 2000, Prior injection with local anaesthetic and the pain and success of intravenous cannulation, Emergency Medicine Journal, 17, pp. 406-408.

Lightowler, J and Elliot, M 1997, Local anaesthetic infiltration prior to arterial puncture for blood gas analysis: a survey of current practice and a randomised double blind placebo controlled trial, Journal of the Royal College of Physicians of London, vol. 31, no. 6, pp. 645-646

Robinson P, Carr S, Pearson S and Frampton C 2007, Lignocaine is a better analgesic than either ethyl chloride or nitrouse oxide for peripheral intravenous cannulation, Emergency Management Australasia, 19, pp. 427-432.

iluvivt, BSN, RN · Apr 13, 2008

since you are able to get a 20 gauge in you should be able to get an 18 gauge with some minor changes in your practice. First the 18 gauge catheter over needle device should be considered. When you look at the device you will notice the needle and bevel are usually a bit longer and once you hit the vein you must thread it a bit further than say a 22 or 20 gauge......and yes even 1/8 inch or so can make a difference. The next thing is to select a vein that will accommodate an 18 gauge...you can also apply a warm pack for a few minutes (if pt condition can tolerate the wait). another trick is just place what you can get and start the IV fluids and in a few hours the veins will look much better. Other tricks ..use two tourniquets.....bp cuff pumped to slightly below pts diastolic ...also remember the flow rate difference between a 20 gauge and an 18 gauge is not that significant also try the deeper veins that you can feel. remember that if you can not see it or feel it do not go for it:nurse: